Planning Semi-Annual Progress Report Form by HC120520032139

VIEWS: 5 PAGES: 11

									                                                                                            Organization                      Grant Number
            DEPARTMENT OF HEALTH AND HUMAN SERVICES
              Health Resources and Services Administration                        UPDATE THIS FIELD WITH THE UPDATE THIS FIELD WITH THE
                                                                                  NAME OF THE ORGANIZATION      GRANT NUMBER AS IT
                 SEMI-ANNUAL PROGRESS REPORT FORM                                   AS IT APPEARS ON THE     APPEARS ON THE NOTICE OF
                                                                                      NOTICE OF AWARD.                AWARD.



Section A - Comprehensive Needs Assessment


Goal A1: Identifying major health issues for the populations to be served, unmet need, barriers to care, etc.

                 Key Action Step(s)                                  Expected Outcome(s)                                Comment(s)
Describe the actions to be taken to fully describe the    What qualititative and quantitative outcomes    What can be cited as having supported or
health care needs of the target population(s) related     have been achieved thus far for each action     impeded your progress toward this goal?
to the following indicators of need:                      step proposed in the approved workplan for
                                                          this goal?
1) The unique characteristics of the target population                                                    What technical assistance resources
   that affect access to primary health care, health                                                      have been used and/or are needed to
   care utilization and/or health status                                                                  assure completion of this goal by the end
                                                                                                          of the project period?
2) Existing primary health care services (including
   mental health/substance abuse and oral health)
   currently available in the applicant’s service area,
   including any gaps in services and/or provider
   shortages, and the role and location of any other
   providers who currently serve the target
   population.

3) IF APPLICABLE- A thorough understanding of the
   specific health care needs and access issues of
   any special populations the applicant organization
   intends to target.
                                                           UPDATE THIS FIELD WITH NARRATIVE               UPDATE THIS FIELD WITH NARRATIVE
     UPDATE THIS FIELD WITH NARRATIVE
                                                            RESPONSES TO THE QUESTION(S)                   RESPONSES TO THE QUESTION(S)
  RESPONSES TO THE QUESTION(S) ABOVE AS
                                                            ABOVE AS THEY PERTAIN TO THE                   ABOVE AS THEY PERTAIN TO THE
 THEY PERTAIN TO THE APPROVED WORKPLAN.
                                                                APPROVED WORKPLAN.                             APPROVED WORKPLAN.
                                                                                                  Organization                    Grant Number
             DEPARTMENT OF HEALTH AND HUMAN SERVICES
               Health Resources and Services Administration                            UPDATE THIS FIELD WITH THE UPDATE THIS FIELD WITH THE
                                                                                       NAME OF THE ORGANIZATION      GRANT NUMBER AS IT
                  SEMI-ANNUAL PROGRESS REPORT FORM                                       AS IT APPEARS ON THE     APPEARS ON THE NOTICE OF
                                                                                           NOTICE OF AWARD.                AWARD.



Goal A2 : Applying for MUA/MUP Designation

                  Key Action Step(s)                                     Expected Outcome(s)                                Comment(s)
Describe the activities that have taken place in order       If no designation exists at this time, what is   What can be cited as having supported or
to obtain designation?                                       the current stage of the MUA/MUP                 impeded your progress toward this goal?
                                                             application process?

                                                                                                              What technical assistance resources
                                                                                                              have been used and/or are needed to
                                                                                                              assure completion of this goal by the end
                                                                                                              of the project period?

                                                               UPDATE THIS FIELD WITH NARRATIVE               UPDATE THIS FIELD WITH NARRATIVE
    UPDATE THIS FIELD WITH NARRATIVE
                                                                RESPONSES TO THE QUESTION(S)                   RESPONSES TO THE QUESTION(S)
 RESPONSES TO THE QUESTION(S) ABOVE AS
                                                                ABOVE AS THEY PERTAIN TO THE                   ABOVE AS THEY PERTAIN TO THE
THEY PERTAIN TO THE APPROVED WORKPLAN.
                                                                    APPROVED WORKPLAN.                             APPROVED WORKPLAN.


Section B – Service Delivery

Goal B1: Developing and appropriate service delivery model based on the comprehensive needs assessment

                  Key Action Step(s)                                     Expected Outcome(s)                                Comment(s)
Describe the key action steps/decisions made                 What qualititative and quantitative outcomes     What can be cited as having supported or
regarding each of the following aspects of service           have been achieved thus far for each action      impeded your progress toward this goal?
delivery:                                                    step proposed in the approved workplan for
1. Proposed service delivery model(s) and sites              this goal?
    (e.g., stand-alone site, school setting, mobile                                                           What technical assistance resources
    clinic, referrals, via contract), including locations,                                                    have been used and/or are needed to
    hours, and after-hours care.                                                                              assure completion of this goal by the end
                                                                                                              of the project period?
2. Key primary health care services to be offered
                                                                    Organization              Grant Number
            DEPARTMENT OF HEALTH AND HUMAN SERVICES
              Health Resources and Services Administration   UPDATE THIS FIELD WITH THE UPDATE THIS FIELD WITH THE
                                                             NAME OF THE ORGANIZATION      GRANT NUMBER AS IT
                 SEMI-ANNUAL PROGRESS REPORT FORM              AS IT APPEARS ON THE     APPEARS ON THE NOTICE OF
                                                                 NOTICE OF AWARD.                AWARD.


   that are appropriate for the community and target
   population(s), to be provided without regard for
   ability to pay and with consideration of cultural
   and linguistic appropriateness

3. Any necessary admitting privileges, access to
   continuum of care, and referral relationships.

4. Enabling services that the proposed health center
   will make available.

5. Clinical and management team staffing plan that
   is appropriate given a proposed number of
   patients and the characteristics and needs of the
   community and target population(s).

6. Schedule of charges consistent with locally
   prevailing rates or charges and a sliding fee scale
   with patient discounts adjusted on the basis of the
   patient’s ability to pay.

7. Quality improvement/quality assurance (QI/QA)
   and risk management that includes clinical
   services and management, maintains patient
   record confidentiality, and involves periodic
   assessment and analysis by clinical staff.

8. Administrative, fiscal, and clinical policies and
   procedures to be approved by an independent
   governing board.
                                                                                              Organization                     Grant Number
             DEPARTMENT OF HEALTH AND HUMAN SERVICES
               Health Resources and Services Administration                         UPDATE THIS FIELD WITH THE UPDATE THIS FIELD WITH THE
                                                                                    NAME OF THE ORGANIZATION      GRANT NUMBER AS IT
                  SEMI-ANNUAL PROGRESS REPORT FORM                                    AS IT APPEARS ON THE     APPEARS ON THE NOTICE OF
                                                                                        NOTICE OF AWARD.                AWARD.



                                                             UPDATE THIS FIELD WITH NARRATIVE              UPDATE THIS FIELD WITH NARRATIVE
    UPDATE THIS FIELD WITH NARRATIVE
                                                              RESPONSES TO THE QUESTION(S)                  RESPONSES TO THE QUESTION(S)
 RESPONSES TO THE QUESTION(S) ABOVE AS
                                                              ABOVE AS THEY PERTAIN TO THE                  ABOVE AS THEY PERTAIN TO THE
THEY PERTAIN TO THE APPROVED WORKPLAN.
                                                                  APPROVED WORKPLAN.                            APPROVED WORKPLAN.

Goal B2: If special populations (e.g., migrant/seasonal agricultural workers, residents of public housing, homeless persons, low-income school
children) are included in the target population, specifying activities related to the identification of the unique access problems and health care
needs of these populations.

                  Key Action Step(s)                                   Expected Outcome(s)                               Comment(s)
FOR SPECIAL POPULATIONS TARGETTED                           What qualititative and quantitative outcomes   What can be cited as having supported or
PLANNING GRANTS- Describe the key action steps              have been achieved thus far for each action    impeded your progress toward this goal?
undertaken to date to identify the unique access            step proposed in the approved workplan for
problems and health care needs of these populations.        this goal?
                                                                                                           What technical assistance resources
                                                                                                           have been used and/or are needed to
                                                                                                           assure completion of this goal by the end
                                                                                                           of the project period?

                                                             UPDATE THIS FIELD WITH NARRATIVE              UPDATE THIS FIELD WITH NARRATIVE
    UPDATE THIS FIELD WITH NARRATIVE
                                                              RESPONSES TO THE QUESTION(S)                  RESPONSES TO THE QUESTION(S)
 RESPONSES TO THE QUESTION(S) ABOVE AS
                                                              ABOVE AS THEY PERTAIN TO THE                  ABOVE AS THEY PERTAIN TO THE
THEY PERTAIN TO THE APPROVED WORKPLAN.
                                                                  APPROVED WORKPLAN.                            APPROVED WORKPLAN.

Goal B3: Facility planning and location selection.

                  Key Action Step(s)                                   Expected Outcome(s)                               Comment(s)
Describe what action steps have been taken to               What qualititative and quantitative outcomes   What can be cited as having supported or
identify the optimal location, facility configuration and   have been achieved thus far for each action    impeded your progress toward this goal?
related square footage, exam rooms, etc.                    step proposed in the approved workplan for
                                                            this goal?
                                                                                                           What technical assistance resources
                                                                                          Organization                     Grant Number
            DEPARTMENT OF HEALTH AND HUMAN SERVICES
              Health Resources and Services Administration                      UPDATE THIS FIELD WITH THE UPDATE THIS FIELD WITH THE
                                                                                NAME OF THE ORGANIZATION      GRANT NUMBER AS IT
                 SEMI-ANNUAL PROGRESS REPORT FORM                                 AS IT APPEARS ON THE     APPEARS ON THE NOTICE OF
                                                                                    NOTICE OF AWARD.                AWARD.


                                                                                                       have been used and/or are needed to
                                                                                                       assure completion of this goal by the end
                                                                                                       of the project period?

                                                         UPDATE THIS FIELD WITH NARRATIVE              UPDATE THIS FIELD WITH NARRATIVE
     UPDATE THIS FIELD WITH NARRATIVE
                                                          RESPONSES TO THE QUESTION(S)                  RESPONSES TO THE QUESTION(S)
  RESPONSES TO THE QUESTION(S) ABOVE AS
                                                          ABOVE AS THEY PERTAIN TO THE                  ABOVE AS THEY PERTAIN TO THE
 THEY PERTAIN TO THE APPROVED WORKPLAN.
                                                              APPROVED WORKPLAN.                            APPROVED WORKPLAN.


Section C - Securing Financial, Professional and Technical Assistance


 Goal C1: Recruiting and retaining key management and other qualified staff.

                 Key Action Step(s)                                Expected Outcome(s)                               Comment(s)
 Describe the progress to date regarding developing a   What qualititative and quantitative outcomes   What can be cited as having supported or
 management team (e.g., Chief Executive Officer,        have been achieved thus far for each action    impeded your progress toward this goal?
 Chief Clinical Officer, Chief Financial Officer)       step proposed in the approved workplan for
                                                        this goal?
                                                                                                       What technical assistance resources
                                                                                                       have been used and/or are needed to
                                                                                                       assure completion of this goal by the end
                                                                                                       of the project period?

                                                         UPDATE THIS FIELD WITH NARRATIVE              UPDATE THIS FIELD WITH NARRATIVE
     UPDATE THIS FIELD WITH NARRATIVE
                                                          RESPONSES TO THE QUESTION(S)                  RESPONSES TO THE QUESTION(S)
  RESPONSES TO THE QUESTION(S) ABOVE AS
                                                          ABOVE AS THEY PERTAIN TO THE                  ABOVE AS THEY PERTAIN TO THE
 THEY PERTAIN TO THE APPROVED WORKPLAN.
                                                              APPROVED WORKPLAN.                            APPROVED WORKPLAN.

 Goal C2: Providing technical assistance and acquiring consultant activities as appropriate.
                                                                                          Organization                     Grant Number
            DEPARTMENT OF HEALTH AND HUMAN SERVICES
              Health Resources and Services Administration                      UPDATE THIS FIELD WITH THE UPDATE THIS FIELD WITH THE
                                                                                NAME OF THE ORGANIZATION      GRANT NUMBER AS IT
                SEMI-ANNUAL PROGRESS REPORT FORM                                  AS IT APPEARS ON THE     APPEARS ON THE NOTICE OF
                                                                                    NOTICE OF AWARD.                AWARD.



                                                                                                                     Comment(s)
                                                                                                       What can be cited as having supported or
                                                                   Expected Outcome(s)
                 Key Action Step(s)                                                                    impeded your progress toward this goal?
                                                        What qualititative and quantitative outcomes
Describe the progress to date securing
                                                        have been achieved thus far for each action
contracts/consultants to assist in the development of
                                                        step proposed in the approved workplan for     What technical assistance resources
the health center.
                                                        this goal?                                     have been used and/or are needed to
                                                                                                       assure completion of this goal by the end
                                                                                                       of the project period?

                                                         UPDATE THIS FIELD WITH NARRATIVE              UPDATE THIS FIELD WITH NARRATIVE
    UPDATE THIS FIELD WITH NARRATIVE
                                                          RESPONSES TO THE QUESTION(S)                  RESPONSES TO THE QUESTION(S)
 RESPONSES TO THE QUESTION(S) ABOVE AS
                                                          ABOVE AS THEY PERTAIN TO THE                  ABOVE AS THEY PERTAIN TO THE
THEY PERTAIN TO THE APPROVED WORKPLAN.
                                                              APPROVED WORKPLAN.                            APPROVED WORKPLAN.

Goal C3: Financial, management, and administrative considerations to the organization related to future operation of a health center

                 Key Action Step(s)                                Expected Outcome(s)                               Comment(s)
Describe the progress to dateon action steps taken to   What qualititative and quantitative outcomes   What can be cited as having supported or
address the financial, management, and                  have been achieved thus far for each action    impeded your progress toward this goal?
administrative needs of a future health center?         step proposed in the approved workplan for
                                                        this goal?
                                                                                                       What technical assistance resources
                                                                                                       have been used and/or are needed to
                                                                                                       assure completion of this goal by the end
                                                                                                       of the project period?

                                                         UPDATE THIS FIELD WITH NARRATIVE              UPDATE THIS FIELD WITH NARRATIVE
    UPDATE THIS FIELD WITH NARRATIVE
                                                          RESPONSES TO THE QUESTION(S)                  RESPONSES TO THE QUESTION(S)
 RESPONSES TO THE QUESTION(S) ABOVE AS
                                                          ABOVE AS THEY PERTAIN TO THE                  ABOVE AS THEY PERTAIN TO THE
THEY PERTAIN TO THE APPROVED WORKPLAN.
                                                              APPROVED WORKPLAN.                            APPROVED WORKPLAN.
                                                                                            Organization                     Grant Number
             DEPARTMENT OF HEALTH AND HUMAN SERVICES
               Health Resources and Services Administration                        UPDATE THIS FIELD WITH THE UPDATE THIS FIELD WITH THE
                                                                                   NAME OF THE ORGANIZATION      GRANT NUMBER AS IT
                 SEMI-ANNUAL PROGRESS REPORT FORM                                    AS IT APPEARS ON THE     APPEARS ON THE NOTICE OF
                                                                                       NOTICE OF AWARD.                AWARD.



 Goal C4: Developing plans for attaining and maintaining long-term viability (i.e., future requirements for space, securing other financial
 support).

                  Key Action Step(s)                                 Expected Outcome(s)                               Comment(s)
 Describe the progress to date regarding identifying      What qualititative and quantitative outcomes   What can be cited as having supported or
 and securing other Federal/State/local/in-kind           have been achieved thus far for each action    impeded your progress toward this goal?
 financial support.                                       step proposed in the approved workplan for
                                                          this goal?
                                                                                                         What technical assistance resources
 Describe action steps taken to identify and/or conduct                                                  have been used and/or are needed to
 long-term strategic mapping/planning.                    Describe an grant application submitted (to    assure completion of this goal by the end
                                                          whom, for what?) and other development         of the project period?
                                                          efforts undertaken?

                                                           UPDATE THIS FIELD WITH NARRATIVE              UPDATE THIS FIELD WITH NARRATIVE
     UPDATE THIS FIELD WITH NARRATIVE
                                                            RESPONSES TO THE QUESTION(S)                  RESPONSES TO THE QUESTION(S)
  RESPONSES TO THE QUESTION(S) ABOVE AS
                                                            ABOVE AS THEY PERTAIN TO THE                  ABOVE AS THEY PERTAIN TO THE
 THEY PERTAIN TO THE APPROVED WORKPLAN.
                                                                APPROVED WORKPLAN.                            APPROVED WORKPLAN.

Section D - Developing Community Involvement/Participation
                                                                                            Organization                     Grant Number
            DEPARTMENT OF HEALTH AND HUMAN SERVICES
              Health Resources and Services Administration                        UPDATE THIS FIELD WITH THE UPDATE THIS FIELD WITH THE
                                                                                  NAME OF THE ORGANIZATION      GRANT NUMBER AS IT
                 SEMI-ANNUAL PROGRESS REPORT FORM                                   AS IT APPEARS ON THE     APPEARS ON THE NOTICE OF
                                                                                      NOTICE OF AWARD.                AWARD.




Goal D1: Developing a Governing Board that aligns with section 330 statutory and regulatory requirements.

                 Key Action Step(s)                                  Expected Outcome(s)                               Comment(s)
Describe progress made to date in gaining/increasing      What qualititative and quantitative outcomes   What can be cited as having supported or
community support and involvement in health center        have been achieved thus far for each action    impeded your progress toward this goal?
planning activities as well as maintaining community      step proposed in the approved workplan for
involvement once the health center is operationa.         this goal?
                                                                                                         What technical assistance resources
Discuss efforts conducted thus far to establish an                                                       have been used and/or are needed to
independent Board of Directors, and recruit Board                                                        assure completion of this goal by the end
members that are representative of the community to                                                      of the project period?
be served and with a broad range of skills and
perspectives in such areas as finance, legal affairs,
business, health, and social services. Include
discussion of progress on the recruitment of both
“consumer/patient” board members and “non-
consumer” board members.


Describe the progress to date on the establishment of
governing board bylaws. Discuss progress made to
attract key individuals with expertise to assist in the
drafting of bylaws.

Summarize all progress made regarding sub-recipient
arrangements, affiliation agreements, and/or other
relationships to which the applicant organization is a
party.
                                                                                            Organization                      Grant Number
             DEPARTMENT OF HEALTH AND HUMAN SERVICES
               Health Resources and Services Administration                       UPDATE THIS FIELD WITH THE UPDATE THIS FIELD WITH THE
                                                                                  NAME OF THE ORGANIZATION      GRANT NUMBER AS IT
                 SEMI-ANNUAL PROGRESS REPORT FORM                                   AS IT APPEARS ON THE     APPEARS ON THE NOTICE OF
                                                                                      NOTICE OF AWARD.                AWARD.



                                                           UPDATE THIS FIELD WITH NARRATIVE              UPDATE THIS FIELD WITH NARRATIVE
     UPDATE THIS FIELD WITH NARRATIVE
                                                            RESPONSES TO THE QUESTION(S)                  RESPONSES TO THE QUESTION(S)
  RESPONSES TO THE QUESTION(S) ABOVE AS
                                                            ABOVE AS THEY PERTAIN TO THE                  ABOVE AS THEY PERTAIN TO THE
 THEY PERTAIN TO THE APPROVED WORKPLAN.
                                                                APPROVED WORKPLAN.                            APPROVED WORKPLAN.

 Goal D2: Developing community support.

                  Key Action Step(s)                                 Expected Outcome(s)                                Comment(s)
 Describe progress on all activities pursued to develop   What qualititative and quantitative outcomes   What can be cited as having supported or
 community support to date.                               have been achieved thus far for each action    impeded your progress toward this goal?
                                                          step proposed in the approved workplan for
                                                          this goal?
                                                                                                         What technical assistance resources
                                                                                                         have been used and/or are needed to
                                                                                                         assure completion of this goal by the end
                                                                                                         of the project period?

                                                           UPDATE THIS FIELD WITH NARRATIVE              UPDATE THIS FIELD WITH NARRATIVE
     UPDATE THIS FIELD WITH NARRATIVE
                                                            RESPONSES TO THE QUESTION(S)                  RESPONSES TO THE QUESTION(S)
  RESPONSES TO THE QUESTION(S) ABOVE AS
                                                            ABOVE AS THEY PERTAIN TO THE                  ABOVE AS THEY PERTAIN TO THE
 THEY PERTAIN TO THE APPROVED WORKPLAN.
                                                                APPROVED WORKPLAN.                            APPROVED WORKPLAN.

Section E - Establishing Collaborative Working Relationships With Other Areas


 Goal E1: Developing linkages/building partnerships with other providers in the community including any federally qualified health centers, health
 departments, local hospitals, and rural health clinics.

                  Key Action Step(s)                                 Expected Outcome(s)                                Comment(s)
 Discuss progress on the establishment of linkages        What qualititative and quantitative outcomes   What can be cited as having supported or
 with other providers and potential stakeholders to       have been achieved thus far for each action    impeded your progress toward this goal?
 enhance collaboration and coordination and prevent       step proposed in the approved workplan for
                                                                                 Organization                   Grant Number
            DEPARTMENT OF HEALTH AND HUMAN SERVICES
              Health Resources and Services Administration               UPDATE THIS FIELD WITH THE UPDATE THIS FIELD WITH THE
                                                                         NAME OF THE ORGANIZATION      GRANT NUMBER AS IT
                 SEMI-ANNUAL PROGRESS REPORT FORM                          AS IT APPEARS ON THE     APPEARS ON THE NOTICE OF
                                                                             NOTICE OF AWARD.                AWARD.


duplication of services within the community.         this goal?
                                                                                            What technical assistance resources
Describe action taken to acquire letters of support
                                                                                            have been used and/or are needed to
(dated within the project period) from these
                                                                                            assure completion of this goal by the end
providers/stakeholders in the service area or an
                                                                                            of the project period?
explanation for why such a letter(s) cannot be
obtained.

FOR SPECIAL POPULATIONS TARGETTED
PLANNING GRANTS- Describe the progress to
reach formal arrangements with organizations that
provide services or support to the proposed special
population.

Discuss efforts to work with other local and State
partners, such as the State Primary Care
Associations (PCAs) and State Health Departments
through the Primary Care Offices (PCOs).

                                                        UPDATE THIS FIELD WITH NARRATIVE    UPDATE THIS FIELD WITH NARRATIVE
    UPDATE THIS FIELD WITH NARRATIVE
                                                         RESPONSES TO THE QUESTION(S)        RESPONSES TO THE QUESTION(S)
 RESPONSES TO THE QUESTION(S) ABOVE AS
                                                         ABOVE AS THEY PERTAIN TO THE        ABOVE AS THEY PERTAIN TO THE
THEY PERTAIN TO THE APPROVED WORKPLAN.
                                                             APPROVED WORKPLAN.                  APPROVED WORKPLAN.

PROJECT OFFICER REVIEW- SEMI ANNUAL REPORT (completed by HRSA)




BRANCH CHIEF REVIEW- SEMI-ANNUAL REPORT (completed by HRSA)
                                                        Organization              Grant Number
DEPARTMENT OF HEALTH AND HUMAN SERVICES
  Health Resources and Services Administration   UPDATE THIS FIELD WITH THE UPDATE THIS FIELD WITH THE
                                                 NAME OF THE ORGANIZATION      GRANT NUMBER AS IT
   SEMI-ANNUAL PROGRESS REPORT FORM                AS IT APPEARS ON THE     APPEARS ON THE NOTICE OF
                                                     NOTICE OF AWARD.                AWARD.

								
To top